NCC191853_NOI Signed Certification_20190913

NCG01 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N, Salisbury Street, 61' Floor
1612 Mail Service Center
Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000),
Under ganatty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of th is project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
0The information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the pet -sot) or persons who manage the system, or those person$
directly responsible for gathering the inforroation,
I will abide by all conditions ofthe 'J . 1,ndand the approved Erosion and
U
/Sediment Control Plan,
if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
P evention Plan) of the I will nonetheless ensure that all conditions of
art 11 of the permit are met on the project at all times.
1, 1 hereby request coverage under the 0000 and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
sarne manner as an individual perrnit.
Name of Project: — IVI C A45i5- P6AA
Legally Responsible Organizational Entity: 0fi4'Sr7A)0'06 C&Vwmucrr04�_4z��_
Legally Responsible Person: Altpec -AA7-7-1S-1F
. I
Title of Legally Responsible Person: V
Date: —"/-
[AVORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 permit,
For more information on signatory requirements, see Port IV, Section 8, Item (6) of the NCG010000 permit.